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On the days of the Recertification survey based on observation, record review, review of hospital policies and procedures, and interviews, the hospital failed to ensure that persons legally responsible to carry out functions specified to promote safe effective care and services for patients to promote patient rights, provide care in a safe setting, and ensure that all personnel meets requirements for training as specified in hospital polices and procedures.

The findings are:

Cross Reference to A0115: the hospital failed to promote and ensure the rights of each patient in the facility that was admitted to the Emergency Room was notified of his/her patient rights and the right of all patients in the facility to receive care in a safe setting for observation of patient's with psychological disorders and to ensure that staff requiring training in Advanced Cardiac Life Support and/or Pediatric Cardiac Life support receives that training in the operating room and the emergency department and in the intensive care unit with a potential to affect all patients receiving care in those areas.

Cross Reference to A0385: The hospital failed to provide the oversight and supervision for the care and services furnished to its patients with a potential to affect all patients in the facility.

Cross Reference to A1160: The facility failed to ensure the written policies and procedures for the Respiratory Department and Sleep/Wake Disorder Lab were reviewed and approved by the medical staff, and the adherence of the respiratory therapy staff to obtain and maintain Advanced Cardiac Life Support (ACLS) certification.

Cross reference to A0886: The hospital failed to have a signed and dated agreement with the Organ Procurement Organization.

On the days of the Recertification Survey based on observation, record review, review of hospital policies and procedures and interview, the hospital failed to promote and ensure the rights of each patient in the facility that was admitted to the Emergency Room was notified of his/her patient rights and the right of all patients in the facility to receive care in a safe setting for observation of patient's with psychological disorders and to ensure that staff requiring training in Advanced Cardiac Life Support and/or Pediatric Cardiac Life support receives that training in the operating room and the emergency department and in the intensive care unit with a potential to affect all patients receiving care in those areas.

The findings are:

Cross reference A-0116: The facility failed to ensure that each hospital patient was given notice of their rights for patients seen in the emergency department which had the potential to affect all patients seen in the hospital's emergency department.

Cross Reference A-0117: The facility failed to ensure emergency department (ED) patients were informed of their rights with a potential for affecting all patients seen in the hospital's emergency department.

Cross Reference A-0144: The hospital failed to provide care and services in a safe setting for 3 of 3 patients who were admitted for psychiatric observation by failing to provide consistent 1:1 direct observation for 3 involuntary committed patients that the physician had assessed the patients were at risk for suicide or homicide, by not facilitating placement of an involuntary committed patient or providing a psychiatric consult for assessment and care of the patients, and by not following protocol for the Emergency Room Observation assessment of the psychiatric patient. The deficient practice has the potential to affect all patient admitted for psychiatric diagnoses that require 1:1 observation. (Patient #18, 19, and 20)

Cross Reference to A0392: The facility failed to ensure licensed nursing personnel required to have Advanced Cardiac Life Support and Pediatric Advanced Life Support certification maintained current certification. The facility failed to follow policies and procedures in place for staffing ratios on the nursing floor.

Cross Reference to A1112: The facility failed to ensure the hospital's Emergency Department (ED) policy 3.10 related to (Advanced Cardiac Life Support) ACLS Protocols were followed for 1 of 4 emergency department physicians and 3 of 7 Registered Nurses in the emergency department with a potential to affect all patients who presented to the Emergency Department.

On the days of the Recertification Survey based on observation, record review, review of hospital policies and procedures, and interviews, the facility failed to ensure that each hospital patient was given notice of their rights for patients seen in the emergency department which had the potential to affect all patients seen in the hospital's emergency department.

The findings are:

On 05/18/10 at 0930, observation in the ED showed the registration clerk registering a patient in the emergency department but the registration clerk did not give the patient any information informing the patient of patient's rights. The registration clerk confirmed the emergency department's policy was to give patient's their patient rights information only if the patient was admitted to the hospital as an inpatient. On 05/19/10 at 1500, the Director of Nursing (DON) and Chief Executive Officer (CEO) revealed that the process of patient notification of their rights had been stopped in the Emergency Department, and this was an "issue that we have not addressed to date". The DON verified that patients seen in the Emergency Department were not given information on patient rights or verbally informed of their patient rights unless the patient was to be admitted to the hospital.

On the days of the Recertification Survey based on observation, record review, review of hospital policies and procedures, and interview, the facility failed to ensure emergency department (ED) patients were informed of their rights with a potential for affecting all patients seen in the hospital's emergency department.

The findings are:

On 05/18/10 at 0930, observation in the ED showed the registration clerk registering a patient in the emergency department but the registration clerk did not give the patient any information informing the patient of patient's rights. The registration clerk confirmed the emergency department's policy was to give patient's their patient rights information only if the patient was admitted to the hospital as an inpatient. On 05/19/10 at 1500, the Director of Nursing (DON) and Chief Executive Officer (CEO) revealed that the process of patient notification of their rights had been stopped in the Emergency Department, and this was an "issue that we have not addressed to date". The DON verified that patients seen in the Emergency Department were not given information on patient rights or verbally informed of their patient rights unless the patient was to be admitted to the hospital.

On the days of the Recertification Survey based on observation, clinical record review, and interview, and hospital policies and procedures, the hospital failed to provide care and services in a safe setting for 3 of 3 patients who were admitted for psychiatric observation by failing to provide consistent 1:1 direct observation for 3 involuntary committed patients that the physician had assessed the patients were at risk for suicide or homicide, by not facilitating placement of an involuntary committed patient or providing a psychiatric consult for assessment and care of the patients, and by not following protocol for the Emergency Room Observation assessment of the psychiatric patient. The deficient practice has the potential to affect all patient admitted for psychiatric diagnoses that require 1:1 observation. (Patient #18, 19, and 20) ; and to ensure that staff receive the required training per hospital policy and procedure to promote the safety of patients and without the required training has the potential to affect all patients in those areas.

The findings are:

On 05/18/10 at 0900, observations the hospital unit (2 East/2 West) showed Certified Nurse Assistant (CNA) #1 was sitting in the hallway outside of patient rooms #219 and #220. On 5/18/10 at 0900, CNA #1 reported that he/she had been assigned 1:1 observation of the patients assigned to room #219 and #220. CNA #1 explained that both of the patients were on 1:1 direct observation, and that the patients were to be within his/her sight at all times. On 5/18/2010 at 1000, Patient #18 located in room #219 was interviewed. The patient stated that he/she "had been admitted over the weekend because he/she had been really messed up".
Observations of the patient's room (219) during the interview revealed an emergency call light cord was attached from the patient's bed to the call light system located on the wall, and curtains had been left in the patient's bathroom . When CNA #1 was interviewed at 0955 related to the call bell cord and curtains left in Room #219, CNA #1 reported that patients were not supposed to have a call bell cord because they could hurt themselves with it. On 5/18/10 at 1000, Charge Nurse #7 reported that an attempt to remove the call light cord from room 219 was made but when staff were not able to stop the call system from ringing in the nurse's station, staff made a decision to leave the call bell cord in room 219. Charge Nurse #7 verified on 05/18/10 at 1000 that since both patients in room 219 and 220 were located next to each other and both patients in those rooms required 1:1 observation, one CNA was assigned to both patients. On 05/18/10 at 1100, after direct observation of patient care and services showed the presence of a call light cord and curtains in one of the patient rooms that had a patient who had been admitted for a suicide attempt was discussed with the Director of Nursing (DON) as well as the observation of other items in the rooms such as a long cord for the electric bed, call light in bathroom, and curtains. The DON reported that those issues should be addressed with the staff. Review of hospital's policy and procedure did not reveal a policy to ensure a safe environment for patients admitted with psychological diagnoses to include potential or actual suicide attempts that included the removal of long cords in the room, drapes, and/or other items that could be harmful for psychiatric patients.

Review of staff assignment sheets for the unit for 5/17/10 for the AM shift, the unit had an observation patient admitted in room 213 and 219. There was no documentation of 1:1 care provided for the observation patients. The CNA assigned to room 213 had a total of 7 patients assigned to him/her. The CNA assigned to room 219 had a total of 6 patients assigned to him/her. The assignment sheet showed that one CNA had called off for the shift, and there was no replacement documented. Review of the unit's assignment sheet for 5/17/10 for the PM shift showed the unit had observation patients in room 213, 219, and 220. The assignment sheet revealed that the observation patient in room 213 had 1:1 observation by a CNA. There was no documentation in the space beside room 219 and 220 that any CNA was assigned 1:1 observation of the patients in these rooms for this shift. Review of unit assignments sheets dated 5/18/10 for the AM shift showed one CNA assigned to observe both room 219 and 218. Review of patient charts showed the patient in Room 219 was admitted for a suicide attempt. The patient in room 220 was admitted for acute psychosis, and the patient in room 213 was admitted for "hearing voices stating that they will kill him". Review of the unit's assignment sheets from 5/17/10 through 5/19/10 showed that staff failed to provide 1:1 observation for 3 of 6 opportunities (50%) for the 3 patients who required 1:1 observation.

On 5/18/10 at 1100, a review of Patient #18's chart revealed that Patient #18 was admitted as an Emergency Room 1:1 Observation patient on 5/14/10 at 1354 for a suicidal attempt by drug overdose with a combination of drugs which include Motrin, Wellbutrin, and Darvocet.
The patient's chart had a hospital form, titled, Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/14/10 and was authenticated by the notary public or probate judge. Specific type of serious harm was recorded as 'Suicide". On Page 2 of the same form under "Note: To Police and Other Officers of the Peace" had this sentence underlined,"No person shall be taken into custody after the expiration date of three days from the date of the certification." The next section of the form, Part II, Page 1, titled, Certificate of Licensed Physician Examination for Emergency Admission, under 1. The UNDERSIGNED LICENSED PHYSICIAN, Have examined the above- named person and am of the opinion that the said individual:" (box) is checked that reads, "Is Mentally Ill AND because of this mental condition CURRENTLY POSES A SUBSTANTIAL RISK of physical harm to self and/or others to the extent that INVOLUNTARY EMERGENCY HOSPITALIZATION is recommended." The physician remarks included but were not limited to: "Took multiple types of medicines out of medicine cabinet. Some are Wellbutrin, Ibuprofen, Tylenol,Darvocet. PT (Patient) slightly lethargic. Pt took pills to end life due to .... taking children away. Medically cleared, Pt still unsure of another attempt." The Emergency Room Physician signed the form on 5/14/10 at 1340. Review of Part II, Page 2 of the form revealed that the sections that read, "I have consulted with the ________Community Mental health Center regarding Preadmission and Screening. If not, state clinical reason________" was blank. The section on the form for the name of the center, signature of face to face screener, and date, and printed name of screener, title and ID number were all blank.

Review of the emergency department's form, Emergency Nursing Record, (triage form) for Patient # 18 showed the patient was triaged as 4 (Semi - Urgent). Chief Complaint reads, "C/O (complained of taking an overdose of Motrin, Wellbutrin, & (and) Darvocet today at 0300 AM." Under suicidal thoughts, the nurse recorded, "Yes". Under additional findings, the nurse recorded,"pt given charcoal 25 gms (grams). *states "the ....(agency) came & took my kids". There was no documentation of a physician order to administer Charcoal 25 grams to the patient on the chart. Review of the nursing assessment showed a note that reads, "UDS (Urine Drug Screen) + Cocaine, + Acet (Acetaminophen) >1359 was circled and 14.7. ASA - and ETOH (alcohol) -".

Review of the patient's emergency treatment form dated 5/14/10 showed Patient #18 had orders for laboratory (Basic Metabolic Panel, Complete Blood Count with Differential, Urinalysis and Urine Culture and Sensitivity if warranted, Hepatic, and Urine Drug Screen). Physician orders on 5/14/10 at 1805 for a Tylenol level 4 hours post last lab draw, Ativan 1 - 2 mg (milligrams) po ( by mouth) q (every) 6 prn (as needed) anxiety or agitation. Physician orders at 0935, read, "Outpt (outpatient) appt (appointment) @ (at) ....". Under other, the physician recorded,"Dx (diagnosis): Suicidal Attempt depression". Review of Patient #18's record showed the hospital form, titled, Medication Administration Record, which revealed Tylenol 650 mg po q 4 prn pain/fever, and Ativan 1 mg po q 6 prn anxiety or agitation. There was no physician order for the administration of Charcoal. The physician wrote orders for the patient for ER (Emergency Room) observation DX: Suicidal attempt". On 5/15/10, the physician wrote orders for Nicotine transdermal 21 mg daily and Fax labs to unit. Physician verbal orders on 5/18/10, read, "May d/c (discontinue) IV (intravenous fluids)". There was no discharge order by the physician on the patient's chart. On the Emergency Room form was a section labeled "Disposition:" which showed the following items were checked: discharged home, written instructions, prescription given to patient, and verbalized understanding'. The nurse authenticated the form but there was no physician signature.

Patient #18's chart showed the Emergency Room physician recorded a progress note on the patient's chart on 5/15/10 at 0910, 5/16/10 at 1100, and 5/18/10 at 0935. There was no physician progress note in the patient's chart dated 5/17/10. Review of facility policy and procedure, titled, Suicide Observation Precautions, reads, "To prevent patient injury to self others from potentially suicidal and/or aggressive/violent patients. For the protection of the patient and staff, certain standards are to be met to care for the potentially suicidal, alcoholic, behavioral health and/or drug over-dosed patient. Policy: ...The patient will not be admitted but will remain an ED patient and shall be assessed a minimum of once a day by the ED physician on duty.... ." The physician progress note dated 5/15/10 at 0910, reads, "S: ...no longer feels suicidal..made a mistake." A: Suicidal attempts/thoughts - improved. P: will await ....availability, possibly stay until Monday". The physician progress note dated 5/16/10 at 1100 AM, reads, " ER .... denies suicidal ideation at this time c/o (complaint/of) feeling shaky at times A: depression, substance abuse, P: Ativan 1 mg po q 6 , mental health assessment in AM". The physician progress note dated 5/18/10 at 0935 reads, "S;...thinking straight, no longer suicidal, A: ...suicidal attempt - no longer suicidal will D/C due to lack of bed & ...unable to assess. F/U at ...". There was no discharge order on the patient's record.

Review of the hospital form, Ongoing Suicide Assessment (RN completes q shift), dated 5/14/10 with no time recorded revealed the form showed 3 levels used to assess the patient's risk for suicide based on the patient's observed behavior with instructions to circle the assessed level, notify the physician of any increase in level to obtain order, For levels II or II, all belts, shoe laces, and drawstrings are removed, and use patient observation checklist for documentation. Review of Patient #18's chart showed the Registered Nurse completed the suicide assessment form on 5/14/10 (1 shift) and 5/16/10 (1 shift). Review of Patient #18"s chart showed the ongoing suicide assessment was conducted by a Registered Nurse on 5/14/10 (admission day) but the time was not recorded. Although the patient was admitted after a suicide attempt, the registered nurse assigned a Level I (mild) when a level III would have been more appropriate based on the criteria to the patient on 5/14/10 which was the day of admission. The Registered Nurse failed to check any items in the symptoms box or interventions box. Intervention for Level I, reads, " #1. Precaution Checks every 30 minutes in Nurses Notes". Review of Patient #18's nurse notes dated 5/14/10 showed the nurse recorded entries on 5/14/10 at 2000, 2200, and 2300. The entry in the nurse notes at 2000 on 5/14/10 addressed the patient's suicide attempt as "No verbalization of self harm. Reports being depressed." There was no suicide assessment form completed on the chart for 5/15/10. Review of the documentation entries in the nurse notes for Patient #18 showed entries on 5/15/10 at 0100, 0300, 0500, 0600, 0800, 1825, and 1930. The nurse recorded on 5/15/10 at 0100 that poison control called to check on patient but there was no further information as to why poison control was called. None of the nurse notes entries on 5/15/10 addressed the patient's state of mind or suicide risk. Review of the patient's chart revealed the suicidal assessment form dated 5/16/10 had no level circled, but the Registered Nurse wrote at the top of the page,"Pt states he/she is not suicidal." The form has the registered nurse signature and date but no time or shift. The rest of the suicidal assessment form is blank. Nurse notes entries were recorded on 5/16/10 at 0600, 0730, 0930 ("states drinks 3 - 4 qts (quarts) beer/day before "the blow up") , 1130 ("Denies suicidal thought or intent"), 1330 ("states," just waiting to see what tomorrow brings. I need to get help for this substance abuse."), 1510 (Ativan given po - pt aware of reason"), 1730, 1930, and 2200. Only 4 of the entries address the patient's potential risk. Patient #18's chart revealed there was no suicidal assessment level completed on 5/17/10 for the patient. Nurse entries on 5/17/10 were 0030, 0300, 1730, 2000("sitting up in bed, denies suicidal thoughts"), 2100 ("denies suicidal thought"), 2200, 2205, and 2300. Only 2 of the documented entries address the patient's suicidal risk. There was no suicidal assessment level and form completed by a registered nurse on the patient's chart for 5/18/10. Nurse entries were at 0000, 0600, 0715 (having any thoughts of suicide, Regrets suicide attempt"), 0825 ("smoking in room, cigarettes and lighter confiscated"), 0905, 0930, 0945("pt to be discharged home"), 1000 ("denies suicidal ideation"), and 1005 ("Personal belongings returned") . The chart had several pages of a form identified as Observation Precautions Flowsheet that had a place to chart the patient's location, verbalization of self - harm, noted inappropriate behaviors, environment check done, and name and title of the person recording on the form. However, the only date on any of the forms was 5/14/10 and the section designed to identify when the observation ended or was continued had no dates or times or check marks to indicate the end or continuation of the observations or successive dates. Since the suicidal assessment forms had not been completed to asses the patient's level each day, then it was difficult to determine the patient's suicide risk level and the type of interventions appropriate for the patient. Based on the level of risk, the Observation Precautions Flowsheet is on an intervention at Level II and Level III. However, the Observation Flowsheet was used for all three patients even though the Suicide Risk Assessment was not used to determine the level of risk or the charting intervention most appropriate for the patient. Review of facility policy and procedure, titled, Suicide Observation Precautions, reads, "....To prevent patient injury to self others from potentially suicidal and/or aggressive/violent patients. For the protection of the patient and staff, certain standards are to be met to care for the potentially suicidal, alcoholic, behavioral health and/or drug over-dosed patient. Policy: Once a patient has been determined at risk for suicide by the physician, a registered nurse must complete a Suicide Assessment for the patient. This assessment shall determine at what risk level the patient is. The assessment must be repeated every shift by a RN. The Suicide Assessment itself provides an algorithm as to what actions should be taken according to each level of risk. Visual Observation: maintain the patient under observation. This may be done by one of the following means: 1. Place patient on 1:1 continuous visual observation by a staff member...Unit Restrictions: The patient will be restricted to the unit except on direct order of the physician...Times for documentation shall be determined by current risk level...".

Patient #18 had a 72 hour limited involuntary Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/14/10 and was authenticated by the notary public or probate judge. The 72 hour period would have expired May 17, 2010. The patient's chart had no progress note by the Emergency physician dated 5/17/2010 that the Emergency room physician had seen the patient on 5/17/10. The chart had no evidence that any discharge planner or case management had seen the patient after admission or that any effort had been conducted to extend the involuntary emergency hospitalization for the patient. There was no documentation that the patient had received any mental health evaluation during the patient's stay. On 5/18/10 at 0935, the physician progress note reads, "S;...thinking straight, no longer suicidal, A: ...suicidal attempt - no longer suicidal, will D/C due to lack of bed & ...unable to assess. F/U at ... (clinic)". There was no physician discharge order in the patient's record. There was no suicidal assessment risk level and form completed by a registered nurse on the patient's chart for 5/18/10. Nurse entries were at 0000, 0600, 0715 (having any thoughts of suicide, Regrets suicide attempt"), 0825 ("smoking in room, cigarettes and lighter confiscated"), 0905, 0930, 0945("pt to be discharged home"), 1000 ("denies suicidal ideation"), and 1005 ("Personal belongings returned") . On the Emergency Room form was a section labeled "Disposition:" which showed the following items were checked: discharged home, written instructions, prescription given to patient, and verbalized understanding'. The nurse authenticated the form and recorded the discharge time as 1012. Review of the hospital form, Emergency Department Discharge Instructions/ Drug Overdose Instructions, showed the form had no date, time, or was authenticated by staff. The instructions checked on the form with an x, read, "Rest today, increase activity tomorrow as tolerated; Resume normal diet; nothing was checked under the medication section; and Follow Up Appointment section had "Follow with mental health (call office for appointment) Phone #: ............ Appointment on 05/21/10 at 10 AM. On 05/18/10 at 1400, clinical record review did not show documentation of a consultation of Mental Health or placement attempts to a psychiatric facility. On 05/18/10 at 1500, Charge Nurse #7 revealed that he/she was unsure of what to do when the 72 hour time frame expired for involuntary emergency admission or the intended disposition of this patient. On 05/18/10 at 1500, the Discharge Planner reported that the patient was admitted on Friday(5/14/10) and he/she was not not notified of the patient's admission. The Discharge Planner reported that he/she was off on Monday (5/17/10) and assumed follow up when he/she returned to work on Tuesday, 05/18/10. The Discharge Planner verified that there had been no follow up for seeking a psychiatric placement for Patient #18 in his/her absence. The Discharge Planner reported that the Infection Control Nurse was supposed to be the back-up for discharge planning. The Discharge Planner reported that the hospital had an informal agreement with Mental Health in that the agency would come over to the hospital to assist with placement, and consultation for these patients, but Mental Health has informed the hospital that the agency can no longer assist the hospital with placement of these patient's due to their own increased case load. There was no evidence that the hospital had addressed the system issue of coverage for discharge planning for these patients on the weekends or in the absence of the discharge planner. On 05/19/10 at 0940, ER Physician #2 revealed that Mental Health was suppose to see the patients that are on ER Psychiatric Observation but the agency doesn't come on the weekends. ER Physician #2 reported that the patient on Involuntary Commitment after 72 hours had to have documented warranted behavior when the 72 hours expired, and/or depending on the patient's behavior of the last 24 hours of the commitment, the involuntary committment could be extended or the patient could be released. Physician #2 reported that the patient was still an emergency department patient and the ER physician will see the patient every day while the patient is on the Medical Surgical floor. ER Physiican #2 explained that the hospital was not accustomed to having 2-3 psychiatric patients at the same time on the Medical Surgical floor. Hospital Policy, Seeking of Placement for Patient In Psychiatric Facility, dated October 2006 and revised July 2009, reads, "Mental Health shall be notified and see patient while they are initially in the ER. If patient presents during the hours of 9am to 5pm, the hospital social worker/discharge planner shall be notified and shall make efforts to expedite the placement of this patient. ....While on Obsevration status, mental health will be in charge of this patient until the time the patient is transferred or released due to contract for safety....". Based on interview with the Discharge Planner, ER Physician, and Director of Nursing, Mental Health was no longer seeing patients for psychological issues and the hospital failed to institute a back up plan for monitoring these patients after the patient presented to the Emergency Department.

Review of Patient 19's chart on 5/18/10 showed the patient presented to the hospital's emergency department on 5/17/10 at 0404 with symptoms of confusion, inappropriate speech, and blaming "us" for breaking promises, and hisotry of Bipolar disorder. The patient's chart had a form, titled, Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/18/10 and was authenticated by the notary public or probate judge. Specific type of serious harm was recorded as "found on exit of 33 off I 95 unsteady- Denies alcohol intake, agitation, obcessive compulsive, taking numerous showers, Does not like the way he/she is treated, threatening w/chairs, violent with staff, and going into other rooms". On Page 2 of the same form under "Note: To Police and Other Officers of the Peace" had this sentence underlined,"No person shall be taken into custody after the expiration date of three days from the date of the certification." The next section of the form, Part II, Page 1, titled, Certificate of Licensed Physician Examination for Emergency Admission, under 1. The UNDERSIGNED LICENSED PHYSICIAN, Have examined the above- named person and am of the opinion that the said individual:" (box) is checked that reads, "Is Mentally Ill AND because of this mental condition CURRENTLY POSES A SUBSTANTIAL RISK of physical harm to self and/or others to the extent that INVOLUNTARY EMERGENCY HOSPITALIZATION is recommended." The physician remarks included but were not limited to: "PT with h/o (history of) Bipolar Disorder, not on any medicines, States last memory was that he/she was heading to ....Georgia but ended up here. Pt still confused & inappropriate speech. Blaming us for breaking promises. Dx: Acute Psychosis." The Emergency Room Physician signed the form on 5/18/10. Review of Part II, Page 2 of the form revealed that the sections that read, "I have consulted with the ________Community Mental health Center regarding Preadmission and Screening. If not, state clinical reason________" was blank. The section on the form for the name of the center, signature of face to face screener, and date, and printed name of screener, title and ID number were all blank. Under the section, Health of Patient, the phsyician checked "yes" by Homicidal or Suicidal tendencies.

Review of Patient #19's chart showed an Emergency Medical Record form, Emergency Medical record Neurological Complaints, and the triage time is recorded as 0400. The patient's Chief Complaint was recorded as "unsteady gait - answers inappropriately, mental status change, headache, dizziness, and fatigue". Under the section labeled psyche was checked: flat affect amd flight of ideas. The patient's record showed the physician ordered 1 liter Normal Saline, labs, heplock, head cat scan, Potassium 20 meq po, and a mental health examination at 0710. The physician recorded the clinical impression as Bipolar disease, hypokalemia, and mild dehydration. Medications ordered were Lithium, Seroquel, Ativan prn, and Haldol prn. The Emergency department phsyican visited the patient on 5/18/10 and 5/19/10. Review of the form, titled, Emergency Department Nurse's Notes showed an entry on 5/17/10 at 1010 that reads, "Mental Health called and will be here to see pt shortly...". On 5/171/0 at 2200, the nurse recorded "denies suicidal thoughts, does hear voices". On 5/18/10 at 0500, the nurse wrote "I'm Mad because of the way people have been treating me but I have been treating people badly myself". Pt unsteady on his feet, when asked to get back in bed pt came toward nurse as if to hit @ him/her." The nurse recorded on 5/18/10 at 1115 that read, "Pt. states he/she is a psychiatrist". On 5/18/10 at 1400, the nurse recorded, "1:1 observation continues". On 5/18/10 at 2000, the nurse recorded, "...Pacing in the room. gait unsteady. Refuses to get back in bed. Becoming agitated." On 5/19/10, the nurse recorded, "Pt climbing in and out of bed. Pacing Room." Review of the hospital form, Ongoing Suicide Assessment (RN completes q shift), dated 5/17/10 at 1600 with no time recorded revealed the 3 levels to assess the patient's risk level for suicide based on the patient's observed behavior with instructions to circle the assessed level, notify the physician of any increase in level to obtain order, For levels II or II, all belts, shoe laces, and drawstrings are removed, and use patient observation checklist for documentation. There was only one suicide risk assessment form on the chart dated 5/17/10 for one shift only. There was no level of risk identified for the patient assessment and therefore, it would be difficult to determine the level of interventions for the nurse to implement . Precaution checks were completed but it was difficult to follow the flow or if the interventions were appropriate since the Registered Nurse had not performed the initial Ongoing Suicide Assessment for the patient. The last recorded nurse entry was on 5/19/10 at 1230 and read, "Given diet, ate sm (small) amt (amount). Up in room - gait unsteady." The last discharge planner note reads,"5/19/10 spoke with ....@..... -calling Ins (insurance) company to see if they will pay for inpt (inpatient) Rehab (rehabiltation).......". As of 5/19/10, there had been no mental health assessment completed on the patient.

On 05/18/10 from 0900 to 1030, observation of CNA #2 revealed that the CNA was sitting in a chair in the hallway outside of patient room #213. PCT #2 was sitting in a chair stationed against a wall with the desk and chair facing towards the nursing station. PCT #2's line of sight was facing away from the patient's room (#213) and was directed toward the nursing station. Patient #20 was in room #213. Review of Patient #20's clinical record revealed Patient #20 was admitted to patient room #213 on 05/16/10 with a diagnosis of Psychosis/Schizophrenia, acute exacerbation. Patient #20 was brought to the emergency Room by Emergency Medical System (EMS) transport in Reeves sleeve and handcuffs. The chart showed the Chief Complaint was "combative at home." Note the patient's chart showed tachycardia with pulse rate of 130. The patient's chart had a form, titled, Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/18/10 and was authenticated by the notary public or probate judge. Specific type of serious harm was recorded as "hearing voices, denies suicidal thoughts, voices stating they will kill him & have attempted too, off all clothes, states they are nasty, calling out for Jesus". On Page 2 of the same form under "Note: To Police and Other Officers of the Peace" had this sentence underlined,"No person shall be taken into custody after the expiration date of three days from the date of the certification." The next section of the form, Part II, Page 1, titled, Certificate of Licensed Physician Examination for Emergency Admission, under 1. The UNDERSIGNED LICENSED PHYSICIAN, Have examined the above- named person and am of the opinion that the said individual:" (box) is checked that reads, "Is Mentally iIl AND because of this mental condition CURRENTLY POSES A SUBSTANTIAL RISK of physical harm to self and/or others to the extent that INVOLUNTARY EMERGENCY HOSPITALIZATION is recommended. "The physician remarks included but were not limited to: was blank. The Emergency Room Physician signed the form on 5/18/10 at . Review of Part II, Page 2 of the form revealed that the sections that read, "I have consulted with the ________Community Mental health Center regarding Preadmission and Screening. If not, state clinical reason________" was blank. The section on the form for the name of the center, signature of face to face screener, and date, and printed name of screener, title and ID number were all blank. Under the section, Health of Patient, the phsyician checked "yes" by Homicidal or Suicidal tendencies. Medications included but were not limited to: Cogentin, Haldol, Serequel, and Depakote. The Emergency Room physician recorded the clinical impression as Psychoses, Schizophrenia acute exeracerbation, and hypokalemia. Although the Emergency Room Physician recorded that the patient was a homicidal/ Suicidal risk, the patient's chart had no Ongoing Suicide Assessment completed q shift by a Registered nurse to assess the patient's risk level and apply the appropriate risk level. The only observation risk forms on the patient's chart was dated 5/17/10. The nurse notes have no dates to delineate when the notes were recorded. The nurse recorded at 1055 that""Pt accused hospital staff of poisoning his/her drink and making him/her have hallucinations". At 1119, the nurse recorded that""Said he/she was afraid and accused the hospital staff of wantign to hurt him". At 1130 , the nurse recorded "Became agitated and said we were destroying him & he tried to leave the room." At 1215, the nurse recorded "Pt asked me if his life was about to end". At 1505, the nurse recorded, "...Pt is talking to himself saying this is not his time to die". At 2000, the nurse recorded "Pt hearing voices, denies suicidal thought, states the voices say they will kill him..." At 0200, the nurse documented "attempting to leave stating "they are coming to kill him". At 0600, the nurse documented "Pt up took all his clothes off states they are "nasty"; calling out for Jesus". The Discharge Planner notes show that the hospital was actively seeking placement for the patient but there was no mental health follow up for the patient documented in the patient's record as of 5/19/10. The nurses failed to complete the suicide risk level every shift to determine the patient's interventional needs.

Review of facility policy and procedure titled Commitment to a Psychiatric Hospital reads, "...Any patient accessing care at this facility who requires psychiatric treatment will be managed through referral and transfer to a psychiatric receiving facility transfer. For patients accessing the hospital through the Emergency Department: The Emergency Department physician will evaluate the patient and determine the need for a psychiatric evaluation. If the patient is deemed in need of psychiatric treatment, the following criteria shall be assessed and documented:...If the patient is a danger to self, staff or others, will be requested continually observe the patient, maintain patient safety..." B. Involuntary Commitment of Adult for Mental Illness 1. If the Emergency Room Physician feels that a patient is mentally ill and because of this condition is likely to cause serious harm to his/herself or others if not immediately hospitalized, an Application for Involuntary Emergency Hospitalization for Mental Illness should be completed. 2. Hampton County Mental health should be notified...during business office hours... 4. the Mental Health Counselor will assist the physician with decisions concerning which facility is utilized...6. Admission must b

On the days of the recertification survey based on observation, record reviews, hospital policies and procedure reviews, and interviews, the hospital failed to provide the oversight and supervision for the care and services furnished to its patients with a potential to affect all patients in the facility.

The findings are:

Cross Reference to A0392: The facility failed to ensure that nursing documented IV (intravenous) catheter changes every 72 hours for 4 of 10 closed records reviewed (Patient #3, 6, 8, and 9), and the Registered Nurses failed to appropriately assess 3 of 3 patients with involuntary commitment for suicidal risk (Patient #18, 19, and 20), and the facility failed to ensure licensed nursing personnel required to have Advanced Cardiac Life Support and Pediatric Advanced Life Support certification maintained current certification. The facility failed to follow policies and procedures in place for staffing ratios on the nursing floor.

Cross Reference to A0395: The hospital failed to ensure that the Registered provided a Suicide Risk Assessment every shift at the appropriate level and followed the appropriate interventions for 3 of 3 emergency room patients admitted for psychological issues to include but limited to: suicide attempt and aggressive behaviors. (Patient #18, 19, and 20)

Cross Reference to A0397: The facility failed to ensure that the Registered Nurse assigned staff to meet the needs of 3 of 3 patients who were required to have 1:1 observation for psychological issues to include but are not limited to suicide precautions. (Patient #18, 19, and 20)

On the days of the Recertification Survey based on record review, facility policy review, and interview, the hospital failed to ensure that all required licensed nursing staff obtain and maintain (Advanced Cardiac Life Support) ACLS certifications and/or PALS (Pediatric Advanced Life Support) for 3 of 7 Registered Nurses in the Operating Room, 3 of 7 Registered Nurses in the Emergency Department, and 2 Registered Nurses in the hospital's Intensive Care Unit (ICU) with a potential to affect all patient populations served in these areas, and provide supervision for the care and services provided by nursing staff for 3 of 3 patients involuntarily committed for psychological issues.(Patient #18, #19, and #20)

The findings are:

Cross Reference to A0392 : The facility failed to ensure that nursing documented IV (intravenous) catheter changes every 72 hours for 4 of 10 closed records reviewed (Patient #3, 6, 8, and 9), and the Registered Nurses failed to appropriately assess 3 of 3 patients with involuntary commitment for suicidal risk. (Patient #18, 19, and 20)

Cross Reference to A0395: The hospital failed to ensure that the Registered provided a Suicide Risk Assessment every shift at the appropriate level and followed the appropriate interventions for 3 of 3 emergency room patients admitted for psychological issues to include but limited to: suicide attempt and aggressive behaviors. (Patient #18, 19, and 20)

Cross Reference to A0397: The facility failed to ensure that the Registered Nurse assigned staff to meet the needs of 3 of 3 patients who were required to have 1:1 observation for psychological issues to include but are not limited to suicide precautions. (Patient #18, 19, and 20)

Cross Reference to A0951: The facility failed to ensure the hospital's Emergency Department (ED) policy 3.10 related to (Advanced Cardiac Life Support) ACLS Protocols were followed for 1 of 4 emergency department physicians and 3 of 7 Registered Nurses in the emergency department with a potential to affect all patients who presented to the Emergency Department.

Cross Reference to A1112: The facility failed to ensure the hospital's Emergency Department (ED) policy 3.10 related to (Advanced Cardiac Life Support) ACLS Protocols were followed for 1 of 4 emergency department physicians and 3 of 7 Registered Nurses in the emergency department with a potential to affect all patients who presented to the Emergency Department.

On the days of the Recertification survey based on interview, record review, and hospital policy review, the facility failed to ensure that nursing documented IV (intravenous) catheter changes every 72 hours for 4 of 10 closed records reviewed (Patient #3, 6, 8, and 9), and the Registered Nurses failed to appropriately assess 3 of 3 patients with involuntary commitment for suicidal risk (Patient #18, 19, and 20), and the facility failed to ensure licensed nursing personnel required to have Advanced Cardiac Life Support and Pediatric Advanced Life Support certification maintained current certification. The facility failed to follow policies and procedures in place for staffing ratios on the nursing floor.

The findings include:

A clinical record review conducted on 5/19/10 at 1350 revealed Patient #3 was admitted to the facility on 12/30/09 and discharged on 1/7/10 (eight days) with the diagnosis of Pneumonia. There was no documentation that the patient's IV catheter dressing was changed during the entire inpatient stay.
A clinical record review conducted on 5/19/10 at 1435 revealed Patient #6 was admitted to the facility on 1/8/10 and discharged on 1/18/10 (10 days) with the diagnosis of Reflux Esophagitis. There was no documentation that the patient's IV catheter dressing site #2 was changed until 1/15/10.
A clinical record review conducted on 5/19/10 at 1600 revealed Patient #8 was admitted to the facility on 1/15/10 and discharged on 1/24/10 (9 days) with the diagnosis of Congestive Heart Failure (CHF). There was no documentation that the patient's IV catheter dressing was changed during the entire inpatient stay.
A clinical record review conducted on 5/19/10 at 1630 revealed Patient #9 was admitted to the facility on 2/16/10 and discharged 2/23/10 (7 days). There was no documentation that the patient's IV catheter's (inserted on 2/19/10) dressing was changed until the IV catheter was discontinued on 2/23/10 at 1015 during discharge process. The findings were verified by Registered Nurse #4 on 5/19/10 at 1515.

Facility Policy # 5.70, revised 8/09, titled, "CARE OF PERIPHERAL AND CENTRAL VASCULAR ACCESS", stated, "...PERIPHERAL ACCESS AND MAINTENANCE GUIDELINES: 1. A patient's IV site will be inspected q (every) 12 hours and PRN (as needed) and documented in Meditech. 2. Site inspection will include inspection and verification of type of fluids infusing and the rate at which infusion is occurring. 3. All IV sites will be routinely changed q 72 hours. If for any reason the IV site is to remain beyond 72 hours, an order must be received from the physician to keep current IV site. Documentation of reasons IV not changed will be required by nursing. 4. IV site dressings will be changed q 72 hours and/or PRN and documented in Meditech. Cap locks to be changed at this time also...".




27544

On 05/18/10 at 0900, observations the hospital unit (2 East/2 West) showed Certified Nurse Assistant (CNA) #1 was sitting in the hallway outside of patient rooms #219 and #220. On 5/18/10 at 0900, CNA #1 reported that he/she had been assigned 1:1 observation of the patients assigned to room #219 and #220. CNA #1 explained that both of the patients were on 1:1 direct observation, and that the patients were to be within his/her sight at all times. On 5/18/2010 at 1000, Patient #18 located in room #219 was interviewed. The patient stated that he/she "had been admitted over the weekend because he/she had been really messed up". Observations of the patient's room (219) during the interview revealed an emergency call light cord was attached from the patient's bed to the call light system located on the wall, and curtains had been left in the patient's bathroom . When CNA #1 was interviewed at 0955 related to the call bell cord and curtains left in Room #219, CNA #1 reported that patients were not supposed to have a call bell cord because they could hurt themselves with it. On 5/18/10 at 1000, Charge Nurse #7 reported that an attempt to remove the call light cord from room 219 was made but when staff were not able to stop the call system from ringing in the nurse's station, staff made a decision to leave the call bell cord in room 219. Charge Nurse #7 verified on 05/18/10 at 1000 that since both patients in room 219 and 220 were located next to each other and both patients in those rooms required 1:1 observation, one CNA was assigned to both patients. On 05/18/10 at 1100, after direct observation of patient care and services showed the presence of a call light cord and curtains in one of the patient rooms that had a patient who had been admitted for a suicide attempt was discussed with the Director of Nursing (DON) as well as the observation of other items in the rooms such as a long cord for the electric bed, call light in bathroom, and curtains. The DON reported that those issues should be addressed with the staff. Review of hospital's policy and procedure did not reveal a policy to ensure a safe environment for patients admitted with psychological diagnoses to include potential or actual suicide attempts that included the removal of long cords in the room, drapes, and/or other items that could be harmful for psychiatric patients. On 5/18/10 at 1100, a review of Patient #18's chart revealed that Patient #18 was admitted as an Emergency Room 1:1 Observation patient on 5/14/10 at 1354 for a suicidal attempt by drug overdose with a combination of drugs which include Motrin, Wellbutrin, and Darvocet. The patient's chart had a hospital form, titled, Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/14/10 and was authenticated by the notary public or probate judge. Specific type of serious harm was recorded as 'Suicide". Review of the emergency department's form, Emergency Nursing Record, (triage form) for Patient # 18 showed the patient was triaged as 4 (Semi - Urgent). Chief Complaint reads, "C/O (complained of taking an overdose of Motrin, Wellbutrin, & (and) Darvocet today at 0300 AM." Under suicidal thoughts, the nurse recorded, "Yes". Under additional findings, the nurse recorded,"pt given charcoal 25 gms (grams). *states "the ....(agency) came & took my kids". There was no documentation of a physician order to administer Charcoal 25 grams to the patient on the chart. Review of the hospital form, Ongoing Suicide Assessment (RN completes q shift), dated 5/14/10 with no time recorded revealed the form showed 3 levels used to assess the patient's risk for suicide based on the patient's observed behavior with instructions to circle the assessed level, notify the physician of any increase in level to obtain order, For levels II or II, all belts, shoe laces, and drawstrings are removed, and use patient observation checklist for documentation. Review of Patient #18's chart showed the Registered Nurse completed the suicide assessment form on 5/14/10 (1 shift) and 5/16/10 (1 shift). Review of Patient #18"s chart showed the ongoing suicide assessment was conducted by a Registered Nurse on 5/14/10 (admission day) but the time was not recorded. Although the patient was admitted after a suicide attempt, the registered nurse assigned a Level I (mild) when a level III would have been more appropriate based on the criteria to the patient on 5/14/10 which was the day of admission. The Registered Nurse failed to check any items in the symptoms box or interventions box. Intervention for Level I, reads, " #1. Precaution Checks every 30 minutes in Nurses Notes". Review of Patient #18's nurse notes dated 5/14/10 showed the nurse recorded entries on 5/14/10 at 2000, 2200, and 2300. The entry in the nurse notes at 2000 on 5/14/10 addressed the patient's suicide attempt as "No verbalization of self harm. Reports being depressed." There was no suicide assessment form completed on the chart for 5/15/10. Review of the documentation entries in the nurse notes for Patient #18 showed entries on 5/15/10 at 0100, 0300, 0500, 0600, 0800, 1825, and 1930. The nurse recorded on 5/15/10 at 0100 that poison control called to check on patient but there was no further information as to why poison control was called. None of the nurse notes entries on 5/15/10 addressed the patient's state of mind or suicide risk. Review of the patient's chart revealed the suicidal assessment form dated 5/16/10 had no level circled, but the Registered Nurse wrote at the top of the page,"Pt states he/she is not suicidal." The form has the registered nurse signature and date but no time or shift. The rest of the suicidal assessment form is blank. Nurse notes entries were recorded on 5/16/10 at 0600, 0730, 0930 ("states drinks 3 - 4 qts (quarts) beer/day before "the blow up") , 1130 ("Denies suicidal thought or intent"), 1330 ("states," just waiting to see what tomorrow brings. I need to get help for this substance abuse."), 1510 (Ativan given po - pt aware of reason"), 1730, 1930, and 2200. Only 4 of the entries address the patient's potential risk. Patient #18's chart revealed there was no suicidal assessment level completed on 5/17/10 for the patient. Nurse entries on 5/17/10 were 0030, 0300, 1730, 2000("sitting up in bed, denies suicidal thoughts"), 2100 ("denies suicidal thought"), 2200, 2205, and 2300. Only 2 of the documented entries address the patient's suicidal risk. There was no suicidal assessment level and form completed by a registered nurse on the patient's chart for 5/18/10. Nurse entries were at 0000, 0600, 0715 (having any thoughts of suicide, Regrets suicide attempt"), 0825 ("smoking in room, cigarettes and lighter confiscated"), 0905, 0930, 0945("pt to be discharged home"), 1000 ("denies suicidal ideation"), and 1005 ("Personal belongings returned") . The chart had several pages of a form identified as Observation Precautions Flowsheet that had a place to chart the patient's location, verbalization of self - harm, noted inappropriate behaviors, environment check done, and name and title of the person recording on the form. However, the only date on any of the forms was 5/14/10 and the section designed to identify when the observation ended or was continued had no dates or times or check marks to indicate the end or continuation of the observations or successive dates. Since the suicidal assessment forms had not been completed to asses the patient's level each day, then it was difficult to determine the patient's suicide risk level and the type of interventions appropriate for the patient. Based on the level of risk, the Observation Precautions Flowsheet is on an intervention at Level II and Level III. However, the Observation Flowsheet was used for all three patients even though the Suicide Risk Assessment was not used to determine the level of risk or the charting intervention most appropriate for the patient. Review of facility policy and procedure, titled, Suicide Observation Precautions, reads, "....To prevent patient injury to self others from potentially suicidal and/or aggressive/violent patients. For the protection of the patient and staff, certain standards are to be met to care for the potentially suicidal, alcoholic, behavioral health and/or drug over-dosed patient. Policy: Once a patient has been determined at risk for suicide by the physician, a registered nurse must complete a Suicide Assessment for the patient. This assessment shall determine at what risk level the patient is. The assessment must be repeated every shift by a RN. The Suicide Assessment itself provides an algorithm as to what actions should be taken according to each level of risk. Visual Observation: maintain the patient under observation. This may be done by one of the following means: 1. Place patient on 1:1 continuous visual observation by a staff member...Unit Restrictions: The patient will be restricted to the unit except on direct order of the physician...Times for documentation shall be determined by current risk level...".

Review of Patient 19's chart on 5/18/10 showed the patient presented to the hospital's emergency department on 5/17/10 at 0404 with symptoms of confusion, inappropriate speech, and blaming "us" for breaking promises, and history of Bipolar disorder. The patient's chart had a form, titled, Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/18/10 and was authenticated by the notary public or probate judge. Specific type of serious harm was recorded as "found on exit of 33 off I 95 unsteady- Denies alcohol intake, agitation, obsessive compulsive, taking numerous showers, Does not like the way he/she is treated, threatening w/chairs, violent with staff, and going into other rooms". Review of the hospital form, Ongoing Suicide Assessment (RN completes q shift), dated 5/17/10 at 1600 with no time recorded revealed the 3 levels to assess the patient's risk level for suicide based on the patient's observed behavior with instructions to circle the assessed level, notify the physician of any increase in level to obtain order, For levels II or II, all belts, shoe laces, and drawstrings are removed, and use patient observation checklist for documentation. There was only one suicide risk assessment form on the chart dated 5/17/10 for one shift only. There was no level of risk identified for the patient assessment and therefore, it would be difficult to determine the level of interventions for the nurse to implement . Precaution checks were completed but it was difficult to follow the flow or if the interventions were appropriate since the Registered Nurse had not performed the initial Ongoing Suicide Assessment for the patient. The last recorded nurse entry was on 5/19/10 at 1230 and read, "Given diet, ate sm (small) amt (amount). Up in room - gait unsteady."

On 05/18/10 from 0900 to 1030, observation of CNA #2 revealed that the CNA was sitting in a chair in the hallway outside of patient room #213. PCT #2 was sitting in a chair stationed against a wall with the desk and chair facing towards the nursing station. PCT #2's line of sight was facing away from the patient's room (#213) and was directed toward the nursing station. Patient #20 was in room #213. Review of Patient #20's clinical record revealed Patient #20 was admitted to patient room #213 on 05/16/10 with a diagnosis of Psychosis/Schizophrenia, acute exacerbation. Patient #20 was brought to the emergency Room by Emergency Medical System (EMS) transport in Reeves sleeve and handcuffs. The chart showed the Chief Complaint was "combative at home." Note the patient's chart showed tachycardia with pulse rate of 130. The patient's chart had a form, titled, Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/18/10 and was authenticated by the notary public or probate judge. Specific type of serious harm was recorded as "hearing voices, denies suicidal thoughts, voices stating they will kill him & have attempted too, off all clothes, states they are nasty, calling out for Jesus". Although the Emergency Room Physician recorded that the patient was a homicidal/ Suicidal risk, the patient's chart had no Ongoing Suicide Assessment completed q shift by a Registered nurse to assess the patient's risk level and apply the appropriate risk level. The only observation risk forms on the patient's chart was dated 5/17/10. The nurse notes have no dates to delineate when the notes were recorded. The nurse recorded at 1055 that""Pt accused hospital staff of poisoning his/her drink and making him/her have hallucinations". At 1119, the nurse recorded that""Said he/she was afraid and accused the hospital staff of wanting to hurt him". At 1130 , the nurse recorded "Became agitated and said we were destroying him & he tried to leave the room." At 1215, the nurse recorded "Pt asked me if his life was about to end". At 1505, the nurse recorded, "...Pt is talking to himself saying this is not his time to die". At 2000, the nurse recorded "Pt hearing voices, denies suicidal thought, states the voices say they will kill him..." At 0200, the nurse documented "attempting to leave stating "they are coming to kill him". At 0600, the nurse documented "Pt up took all his clothes off states they are "nasty"; calling out for Jesus". The Discharge Planner notes show that the hospital was actively seeking placement for the patient but there was no mental health follow up for the patient documented in the patient's record as of 5/19/10. The nurses failed to complete the suicide risk level every shift to determine the patient's interventional needs.
Review of facility policy and procedure titled Commitment to a Psychiatric Hospital reads, "...Any patient accessing care at this facility who requires psychiatric treatment will be managed through referral and transfer to a psychiatric receiving facility transfer. For patients accessing the hospital through the Emergency Department: The Emergency Department physician will evaluate the patient and determine the need for a psychiatric evaluation. If the patient is deemed in need of psychiatric treatment, the following criteria shall be assessed and documented:...If the patient is a danger to self, staff or others, will be requested continually observe the patient, maintain patient safety..."

Review of facility policy and procedure titled Suicide Observation Precautions reads, " To prevent patient injury to self others from potentially suicidal and/or aggressive/violent patients. For the protection of the patient and staff, certain standards are to be met to care for the potentially suicidal, alcoholic, behavioral health and/or drug over-dosed patient. Policy:...Any patient, who in judgement of the physician and/ or the RN presents danger to him/herself or others, and needs psychiatric services, should not routinely be admitted... Arrangements for consultation, and transfer should be made to an appropriate institution. Should the institution have no bed and an Emergency Department(ED) patient must be held ... the patient shall be kept as an ED patient.... Indications for Initiation of Observation Status:1. verbalization of suicidal thoughts. 2. Evidence of known or suspected self-inflicted injury or overdose...4. Thought processes impaired to the degree that patient may be a potential harm to him/her or others...Procedure: For an ED patient needing observation while waiting on a bed, the patient may remain the the ED or be taken upstairs to the in-patient unit and be assigned 1:1 care. The patient will not be admitted but will remain an ED patient and shall be assessed a minimum of once a day by the ED physician on duty.... Once a patient has been determined at risk for suicide by the physician, a registered nurse must complete a Suicide Assessment for the patient. This assessment shall determine at what risk level the patient is. The assessment must be repeated every shift by a RN. The Suicide Assessment itself provides an algorithm as to what actions should be taken according to each level of risk. Visual Observation: maintain the patient under observation. This may be done by one of the following means: 1. Place patient on 1:1 continuous visual observation by a staff member..."








28552

On 05/19/10 at 1430, after review of licensed nursing personnel it was revealed three of seven RN personnel were not up to date on their ACLS and/or PALS certification in the Operating Room and two of the RN personnel working in the ICU. This was verified by the Director of Nursing who stated she was aware several staff members were not current in their ACLS and or PALS certification. On 05/19/10 at 1430, a review of licensed nursing personnel files and physician credentialing files revealed one (1) of four (4) ED physicians had expired ACLS certification and three of seven Registered Nurses had expired ACLS certification. The finding was verified by the Director of Nursing (DON) who stated that he/she was aware several staff members were not current in their ACLS certification. Emergency Department policy, 3.10 ACLS Protocols, reads, "All Emergency Department licensed nursing staff and ER physicians are required to take and stay up to date on their ACLS certification. .....".

On the days of the Recertification survey based on record review and interview, the hospital failed to ensure that the Registered provided a Suicide Risk Assessment every shift at the appropriate level and followed the appropriate interventions for 3 of 3 emergency room patients admitted for psychological issues to include but limited to: suicide attempt and aggressive behaviors. (Patient #18, 19, and 20)

The findings are:

On 5/18/10 at 1100, a review of Patient #18's chart revealed that Patient #18 was admitted as an Emergency Room 1:1 Observation patient on 5/14/10 at 1354 for a suicidal attempt by drug overdose with a combination of drugs which include Motrin, Wellbutrin, and Darvocet. Review of the hospital form, Ongoing Suicide Assessment (RN completes q shift), dated 5/14/10 with no time recorded revealed the form showed 3 levels used to assess the patient's risk for suicide based on the patient's observed behavior with instructions to circle the assessed level, notify the physician of any increase in level to obtain order, For levels II or II, all belts, shoe laces, and drawstrings are removed, and use patient observation checklist for documentation. Review of Patient #18's chart showed the Registered Nurse completed the suicide assessment form on 5/14/10 (1 shift) and 5/16/10 (1 shift). Review of Patient #18"s chart showed the ongoing suicide assessment was conducted by a Registered Nurse on 5/14/10 (admission day) but the time was not recorded. Although the patient was admitted after a suicide attempt, the registered nurse assigned a Level I (mild) when a level III would have been more appropriate based on the criteria to the patient on 5/14/10 which was the day of admission. The Registered Nurse failed to check any items in the symptoms box or interventions box. Intervention for Level I, reads, " #1. Precaution Checks every 30 minutes in Nurses Notes".
Review of Patient 19's chart on 5/18/10 showed the patient presented to the hospital's emergency department on 5/17/10 at 0404 with symptoms of confusion, inappropriate speech, and blaming "us" for breaking promises, and history of Bipolar disorder. The patient's chart had a form, titled, Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/18/10 and was authenticated by the notary public or probate judge. Specific type of serious harm was recorded as "found on exit of 33 off I 95 unsteady- Denies alcohol intake, agitation, obsessive compulsive, taking numerous showers, Does not like the way he/she is treated, threatening w/chairs, violent with staff, and going into other rooms". Review of the hospital form, Ongoing Suicide Assessment (RN completes q shift), dated 5/17/10 at 1600 with no time recorded revealed the 3 levels to assess the patient's risk level for suicide based on the patient's observed behavior with instructions to circle the assessed level, notify the physician of any increase in level to obtain order, For levels II or II, all belts, shoe laces, and drawstrings are removed, and use patient observation checklist for documentation. There was only one suicide risk assessment form on the chart dated 5/17/10 for one shift only. There was no level of risk identified for the patient assessment and therefore, it would be difficult to determine the level of interventions for the nurse to implement . Precaution checks were completed but it was difficult to follow the flow or if the interventions were appropriate since the Registered Nurse had not performed the initial Ongoing Suicide Assessment for the patient.
Review of Patient #20's clinical record revealed Patient #20 was admitted to patient room #213 on 05/16/10 with a diagnosis of Psychosis/Schizophrenia, acute exacerbation. Patient #20 was brought to the emergency Room by Emergency Medical System (EMS) transport in Reeves sleeve and handcuffs. The chart showed the Chief Complaint was "combative at home." Note the patient's chart showed tachycardia with pulse rate of 130. The patient's chart had a form, titled, Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/18/10 and was authenticated by the notary public or probate judge. Specific type of serious harm was recorded as "hearing voices, denies suicidal thoughts, voices stating they will kill him & have attempted too, off all clothes, states they are nasty, calling out for Jesus". Although the Emergency Room Physician recorded that the patient was a homicidal/ Suicidal risk, the patient's chart had no Ongoing Suicide Assessment completed q shift by a Registered nurse to assess the patient's risk level and apply the appropriate risk level. The only observation risk forms on the patient's chart was dated 5/17/10.

Review of facility policy and procedure, titled, Suicide Observation Precautions, reads, "....To prevent patient injury to self others from potentially suicidal and/or aggressive/violent patients. For the protection of the patient and staff, certain standards are to be met to care for the potentially suicidal, alcoholic, behavioral health and/or drug over-dosed patient. Policy: Once a patient has been determined at risk for suicide by the physician, a registered nurse must complete a Suicide Assessment for the patient. This assessment shall determine at what risk level the patient is. The assessment must be repeated every shift by a RN. The Suicide Assessment itself provides an algorithm as to what actions should be taken according to each level of risk. Visual Observation: maintain the patient under observation. This may be done by one of the following means: 1. Place patient on 1:1 continuous visual observation by a staff member...Unit Restrictions: The patient will be restricted to the unit except on direct order of the physician...Times for documentation shall be determined by current risk level...".

Review of Patient 19's chart on 5/18/10 showed the patient presented to the hospital's emergency department on 5/17/10 at 0404 with symptoms of confusion, inappropriate speech, and blaming "us" for breaking promises, and history of Bipolar disorder. The patient's chart had a form, titled, Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/18/10 and was authenticated by the notary public or probate judge. Specific type of serious harm was recorded as "found on exit of 33 off I 95 unsteady- Denies alcohol intake, agitation, obsessive compulsive, taking numerous showers, Does not like the way he/she is treated, threatening w/chairs, violent with staff, and going into other rooms". Review of Patient #20's clinical record revealed Patient #20 was admitted to patient room #213 on 05/16/10 with a diagnosis of Psychosis/Schizophrenia, acute exacerbation. Patient #20 was brought to the emergency Room by Emergency Medical System (EMS) transport in Reeves sleeve and handcuffs. The chart showed the Chief Complaint was "combative at home." Note the patient's chart showed tachycardia with pulse rate of 130. The patient's chart had a form, titled, Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/18/10 and was authenticated by the notary public or probate judge. Specific type of serious harm was recorded as "hearing voices, denies suicidal thoughts, voices stating they will kill him & have attempted too, off all clothes, states they are nasty, calling out for Jesus". Review of the hospital form, Ongoing Suicide Assessment (RN completes q shift), dated 5/17/10 at 1600 with no time recorded revealed the 3 levels to assess the patient's risk level for suicide based on the patient's observed behavior with instructions to circle the assessed level, notify the physician of any increase in level to obtain order, For levels II or II, all belts, shoe laces, and drawstrings are removed, and use patient observation checklist for documentation. There was only one suicide risk assessment form on the chart dated 5/17/10 for one shift only. There was no level of risk identified for the patient assessment and therefore, it would be difficult to determine the level of interventions for the nurse to implement . Precaution checks were completed but it was difficult to follow the flow or if the interventions were appropriate since the Registered Nurse had not performed the initial Ongoing Suicide Assessment for the patient. The last recorded nurse entry was on 5/19/10 at 1230 and read, "Given diet, ate sm (small) amt (amount). Up in room - gait unsteady."

Patient #20 was brought to the emergency Room by Emergency Medical System (EMS) transport in Reeves sleeve and handcuffs. The chart showed the Chief Complaint was "combative at home." Note the patient's chart showed tachycardia with pulse rate of 130. The patient's chart had a form, titled, Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/18/10 and was authenticated by the notary public or probate judge. Specific type of serious harm was recorded as "hearing voices, denies suicidal thoughts, voices stating they will kill him & have attempted too, off all clothes, states they are nasty, calling out for Jesus". Although the Emergency Room Physician recorded that the patient was a homicidal/ Suicidal risk, the patient's chart had no Ongoing Suicide Assessment completed q shift by a Registered nurse to assess the patient's risk level and apply the appropriate risk level. The only observation risk forms on the patient's chart was dated 5/17/10. The nurse notes have no dates to delineate when the notes were recorded. The nurse recorded at 1055 that""Pt accused hospital staff of poisoning his/her drink and making him/her have hallucinations". At 1119, the nurse recorded that""Said he/she was afraid and accused the hospital staff of wanting to hurt him". At 1130 , the nurse recorded "Became agitated and said we were destroying him & he tried to leave the room." At 1215, the nurse recorded "Pt asked me if his life was about to end". At 1505, the nurse recorded, "...Pt is talking to himself saying this is not his time to die". At 2000, the nurse recorded "Pt hearing voices, denies suicidal thought, states the voices say they will kill him..." At 0200, the nurse documented "attempting to leave stating "they are coming to kill him". At 0600, the nurse documented "Pt up took all his clothes off states they are "nasty"; calling out for Jesus". The Discharge Planner notes show that the hospital was actively seeking placement for the patient but there was no mental health follow up for the patient documented in the patient's record as of 5/19/10. The nurses failed to complete the suicide risk level every shift to determine the patient's interventional needs.

On the days of the hospitals's Recertification survey based on record observations, record reviews, interviews, and facility policy and procedure, the facility failed to ensure that the Registered Nurse assigned staff to meet the needs of 3 of 3 patients who were required to have 1:1 observation for psychological issues to include but are not limited to suicide precautions. (Patient #18, 19, and 20)

The findings are:

On 05/18/10 at 0900, observations the hospital unit (2 East/2 West) showed Certified Nurse Assistant (CNA) #1 was sitting in the hallway outside of patient rooms #219 and #220. On 5/18/10 at 0900, CNA #1 reported that he/she had been assigned 1:1 observation of the patients assigned to room #219 and #220. CNA #1 explained that both of the patients were on 1:1 direct observation, and that the patients were to be within his/her sight at all times. On 05/18/10 from 0900 to 1030, observation of CNA #2 revealed that the CNA was sitting in a chair in the hallway outside of patient room #213. PCT #2 was sitting in a chair stationed against a wall with the desk and chair facing towards the nursing station. PCT #2's line of sight was facing away from the patient's room (#213) and was directed toward the nursing station. Patient #20 was in room #213. Review of Patient #20's clinical record revealed Patient #20 was admitted to patient room #213 on 05/16/10 with a diagnosis of Psychosis/Schizophrenia, acute exacerbation.

On 5/18/10 at 1100, a review of Patient #18's chart revealed that Patient #18 was admitted as an Emergency Room 1:1 Observation patient on 5/14/10 at 1354 for a suicidal attempt by drug overdose with a combination of drugs which include Motrin, Wellbutrin, and Darvocet. Review of Patient 19's chart on 5/18/10 showed the patient presented to the hospital's emergency department on 5/17/10 at 0404 with symptoms of confusion, inappropriate speech, and blaming "us" for breaking promises, and history of Bipolar disorder. The patient's chart had a form, titled, Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/18/10 and was authenticated by the notary public or probate judge. Specific type of serious harm was recorded as "found on exit of 33 off I 95 unsteady- Denies alcohol intake, agitation, obsessive compulsive, taking numerous showers, Does not like the way he/she is treated, threatening w/chairs, violent with staff, and going into other rooms". Review of Patient #20's clinical record revealed Patient #20 was admitted to patient room #213 on 05/16/10 with a diagnosis of Psychosis/Schizophrenia, acute exacerbation. Patient #20 was brought to the emergency Room by Emergency Medical System (EMS) transport in Reeves sleeve and handcuffs. The chart showed the Chief Complaint was "combative at home." Note the patient's chart showed tachycardia with pulse rate of 130. The patient's chart had a form, titled, Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/18/10 and was authenticated by the notary public or probate judge. Specific type of serious harm was recorded as "hearing voices, denies suicidal thoughts, voices stating they will kill him & have attempted too, off all clothes, states they are nasty, calling out for Jesus".

Review of staff assignment sheets for the unit for 5/17/10 for the AM shift, the unit had an observation patient admitted in room 213 and 219. There was no documentation of 1:1 care provided for the observation patients. The CNA assigned to room 213 had a total of 7 patients assigned to him/her. The CNA assigned to room 219 had a total of 6 patients assigned to him/her. The assignment sheet showed that one CNA had called off for the shift, and there was no replacement documented. Review of the unit's assignment sheet for 5/17/10 for the PM shift showed the unit had observation patients in room 213, 219, and 220. The assignment sheet revealed that the observation patient in room 213 had 1:1 observation by a CNA. There was no documentation in the space beside room 219 and 220 that any CNA was assigned 1:1 observation of the patients in these rooms for this shift. Review of unit assignments sheets dated 5/18/10 for the AM shift showed one CNA assigned to observe both room 219 and 218. Review of patient charts showed the patient in Room 219 was admitted for a suicide attempt. The patient in room 220 was admitted for acute psychosis, and the patient in room 213 was admitted for "hearing voices stating that they will kill him". Review of the unit's assignment sheets from 5/17/10 through 5/19/10 showed that staff failed to provide 1:1 observation for 3 of 6 opportunities (50%) for the 3 patients who required 1:1 observation.

Once a patient has been determined at risk for suicide by the physician, a registered nurse must complete a Suicide Assessment for the patient. This assessment shall determine at what risk level the patient is. The assessment must be repeated every shift by a RN. The Suicide Assessment itself provides an algorithm as to what actions should be taken according to each level of risk. Visual Observation: maintain the patient under observation. This may be done by one of the following means: 1. Place patient on 1:1 continuous visual observation by a staff member...Unit Restrictions: The patient will be restricted to the unit except on direct order of the physician.

Review of hospital policy and procedure titled Nurse Staffing reads, " ...Policy/Procedure: 2. A staff in numbers relative to patient census and patient acuity will cover the units...".

On the days of the Recertification Survey based on interview, clinical record review, and hospital policy and procedure review, the facility failed to ensure all patient clinical records were completed by containing the date and time in which physician signed medical orders, consultation reports, operative notes, history and physical reports, and discharge summary reports for 5 of 10 closed records (Patient #1, 2, 3, 6, 7, and 8), and the date on nursing flowsheets, portions of the record not containing patient identifiers, and authentication by the physician for 3 of 20 open records. (Patient #18, 19, and 20)

The findings include:

A clinical record review conducted on 5/18/10 at 1400 revealed Patient #1 was admitted to the facility on 1/5/10 and discharged on 1/6/10 with the diagnosis of Right Breast Mass Incision. The GENERAL SURGERY OPERATIVE REPORT dictated on 1/5/10 did not contain the date and time when the physician signed the report.
A clinical record review conducted on 5/19/10 at 1345 revealed Patient #2 was admitted to the facility on 2/17/10 and discharged on 2/20/10 with the diagnosis of Abdominal Aortic Aneurysm With Leakage. The patient's DISCHARGE SUMMARY dictated on 3/5/10 did not contain the date and time when the physician signed the report. The patient's ADMISSION HISTORY & PHYSICAL report dictated on 2/17/10 and the Physician Orders for Life-Sustaining Treatment did not contain the date and time when the physician signed the report and the orders.
A clinical record review conducted on 5/19/10 at 1350 revealed Patient #3 was admitted to the facility on 12/30/09 and discharged on 1/7/10 with the diagnosis of Pneumonia. The DISCHARGE SUMMARY report dictated on 1/23/10 did not contain the date and time when the physician signed the report. The ADMISSION HISTORY & PHYSICAL report dictated on 12/31/09 did not contain the date and time when the physician signed the report.
A clinical record review conducted on 5/19/10 at 1435 revealed Patient #6 was admitted to the facility on 1/8/10 and discharged on 1/18/10 with the diagnosis of Reflux Esophagitis. The DISCHARGE SUMMARY report dictated on 1/18/10 did not contain the date and time when the physician signed the report. The ADMISSION HISTORY & PHYSICAL report dictated on 1/8/10 did not contain the date and time when the physician signed the notes. Two CONSULTATION NOTES dictated on 1/8/10 did not contain the date and time when the physician signed the report. The GENERAL SURGERY OPERATIVE REPORT dictated on 1/11/10 did not contain the date and time when the physician signed the report.
A clinical record review conducted on 5/19/10 at 1550 revealed Patient #7 was admitted to the facility on 1/6/10 and discharged on 1/7/10 with the diagnosis of Weakness Secondary To Past CVA (Cardiovascular Accident). The DISCHARGE SUMMARY note dictated on 2/15/10 did not contain the date and time when the physician signed the report. The ADMISSION HISTORY & PHYSICAL report dictated on 1/6/10 did not contain the date and time when the physician signed the report. Three verbal physician orders dated 1/7/10 did not contain the date and time when the physician signed the orders.
A clinical record review conducted on 5/19/10 at 1600 revealed Patient #8 was admitted to the facility on 1/15/10 and discharged on 1/24/10 with the diagnosis of Congestive Heart Failure (CHF). The DISCHARGE SUMMARY report dictated on 3/15/10 did not contain the date and time when the physician signed the report. A verbal physician order dated 1/16/10 did not contain the date and time when the physician signed the order. The findings were verified by Registered Nurse #4 on 5/19/10 at 1515.

Facility Policy #2.35, revised 1/01, titled, "Verbal Orders", stated, "Policy: Verbal orders must be signed, dated and timed within 48 hours, except for restraint and narcotics...".
Facility Policy #2.10, revised 1/01, titled, "What a record needs to be complete", stated, "Policy: All information must be written in record as soon after occurrence as possible. If not it is considered incomplete...1. General Medical/Surgical/Swing Bed:...M. Doctors orders: a. All orders must be signed and dated by the responsible physician. b. Each record must have a signed discharge order. If there is none, ask for one. c. All orders are to be signed within 48 hours. d. Verbal orders can only be taken by qualified personnel. (i.e.: RN, PharmD's, Respiratory, etc)...".













27544

On 05-18-10 at 1400, clinical record review of Patient #18 who was admitted to the hospital emergency department on 05-14-10 at 1324 with the diagnosis of Suicide Attempt/Depression reveals, Extended Stay Nurses Notes dated 05-17-10 are written for 2 days without a date notation. The nurse was signing the note with a 2 letter initial instead of a signature. The Physician note dated 05-15-10 at 0910 was unsigned by the physician. The added entry on the Emergency Room Medical Decision making: for 05-18-10 was not signed by the physician. The added entry on the Emergency Room Discharge Instruction Sheet was not timed, dated, or signed by the physician. There were multiple pages of the Psychiatric Observation Record that were not dated, and the signatures were represented by initials, without titles. There were 2 pages of Psychiatric Observation Records that were not identified with name of the patient or the dates of service.

On 05-18-10 at 1500, clinical record review of Patient #19 who was admitted to the hospital emergency department, under ER Observation on 05-17-10 at 0404 with the diagnosis of Bipolar Disease/Hypokalemia/Dehydration-mild, reveals that Extended Stay Nurses Notes dated 05-19-10 are signed with initials. The same person was signing the Psychiatric Observation Record dated 05-17-10 with initials. A page of the emergency room record starting with the Nursing Assessment review was not identified with the patients name. #1 Physician Order was not dated/timed by physician. Progress note of 05-18-10 does not have the patient identification. An observation Precaution Sheet does not have patient identification nor the date of service.

On 05-18-10 at 1530, clinical record review of Patient #20 who was admitted on 05-16-10 with a diagnosis of Psychosis/Schizophrenia,acute exacerbation, reveals that 2 pages of Extended Stay Nurses Notes are not dated. Page 2 of the Emergency Room record, and the form titled Additional Notes does not have patient identification. One page of a Observation Precautions Flowsheet was not dated.

On 05-18-10 at 1400 it is confirmed with the Director of Nursing that multiple pages in the clinical record are not dated, that disciplines are signing with initials and no titles, and pages within the clinical record do not have patient identification.

Review of policy and procedure titled Patient Care Documentation in the Medical Record reads, "...2. All documents in the medical record will be located under patient name. 3. Each entry will be dated, timed and contain clinical staff"s electronic signature...."

On the days of the Recertification Survey based on interview, record review, and hospital policy review, the facility failed to ensure that all verbal physician orders were authenticated within a 48 hour timeframe for 2 of 10 closed patient records. (Patient #7 and 8)

The findings are:

A clinical record review conducted on 5/19/10 at 1550 revealed Patient #7 was admitted to the facility on 1/6/10 and discharged on 1/7/10 with the diagnosis of Weakness Secondary To Past CVA (Cardiovascular Accident). Three verbal physician orders dated 1/7/10 did not contain the date and time when the physician authenticated the orders. A clinical record review conducted on 5/19/10 at 1600 revealed Patient #8 was admitted to the facility on 1/15/10 and discharged on 1/24/10 with the diagnosis of Congestive Heart Failure (CHF). A verbal physician order dated 1/16/10 did not contain the date and time when the physician authenticated the order. These findings were verified by Registered Nurse #4 on 5/19/10 at 1515. Facility Policy #2.35, revised 1/01, titled, "Verbal Orders", stated, "Policy: Verbal orders must be signed, dated and timed within 48 hours, except for restraint and narcotics...".
Facility Policy #2.10, revised 1/01, titled, "What a record needs to be complete", stated, "Policy: All information must be written in record as soon after occurrence as possible. If not it is considered incomplete...1. General Medical/Surgical/Swing Bed:...M. Doctors orders: a. All orders must be signed and dated by the responsible physician. b. Each record must have a signed discharge order. If there is none, ask for one. c. All orders are to be signed within 48 hours. d. Verbal orders can only be taken by qualified personnel. (i.e.: RN, PharmD's, Respiratory, etc)...".

On the days of the Recertification Survey based on medical record review and staff interview, the facility failed to ensure the proper execution of informed consent for surgery for 1 of 1 closed patient records. (Patient #1)

The findings include:

A clinical record review conducted on 5/18/10 at 1400 revealed Patient #1 was admitted to the facility on 1/5/10 and discharged on 1/6/10 with the diagnosis of Right Breast Mass Incision. The hospital form, "Consent for Procedure" was signed and dated by the physician and patient on 11/10/09 for a Bilateral Breast Reduction which was performed on 1/5/10. The patient's consent was obtained greater than 30 days prior to the procedure. On 5/18/10 at 1430, the Director of Nursing reported the patient's consent should have been obtained within a month of the procedure. Facility Policy #3.35, titled, "INFORMED CONSENT" states, "POLICY: A patient or an authorized person acting on the patient's behalf must receive informed consent prior to the following: a. A surgical procedure or diagnostic test performed under general, spinal, or major regional anesthesia...5. The informed consent is valid for 30 days...".

On the days of the Recertification Survey based on interview and clinical record review, the hospital failed to document a discharge order for 1 of 20 clinical records reviewed. (Patient #18)

The findings are:

On 05-19-10 at 1100, a review of Patient #18's record showed the patient, who was admitted to the hospital's emergency department on 05-14-10 at 1324 with the diagnosis of Suicide Attempt/Depression was discharged on 05-18-10 at 1030 revealed that an order to from the physician to discharge the patient was not documented. The finding was confirmed with the Director of Nursing and the Discharge Planner on 05-19-10 at 1130.
Review of facility policy and procedure, titled, What a record needs to be complete, reads, "...b. Each record must have a signed discharge order...".

On the days of the Recertification Survey based on record review, and hospital policy review, the facility failed to ensure all patient clinical records contained a discharge summary for 2 of 10 closed patient records. (Patient #9 and 10)

The findings include:

A clinical record review conducted on 5/19/10 at 1630 revealed Patient #9 was admitted to the facility on 2/16/10 and discharged on 2/23/10. The clinical record did not contain a discharge summary. A clinical record review conducted on 5/19/10 at 1700 revealed Patient #10 was admitted to the facility on 1/21/10 and discharged on 1/27/10. The clinical record did not contain a discharge summary. The findings were verified by Registered Nurse #4 on 5/19/10 at 1515. Facility Policy #2.10, revised 1/01, titled, "What a record needs to be complete", states, "Policy: All information must be written in record as soon after occurrence as possible. If not it is considered incomplete...1. General Medical/Surgical/Swing Bed:...B. Discharge Summary: a. A Discharge Summary must be done on all patients that remain in the hospital over 48 hours, and on all Deaths. If dictated by a PA (Physician Assistant) or Midwife, must be co-signed by attending. Report must contain: procedures performed, significant findings, discharge instructions, treatment rendered during the hospital stay, and discharge diagnosis...".

On the days of the Recertification Survey based on observation, record review, review of hospital policies and procedures, and interview, the facility failed to ensure medications were labeled properly, that there were no medications outdated, and the facility Pharmacy's policies and procedures were followed.

The findings are:

On 05/18/10 at 1045, observations during a tour of the Emergency Department Room 7 with Registered Nurse (RN) #4 showed a 250 cc (cubic centimeters) bottle of Normal Saline for irrigation was opened and labeled with date of 05/10/10. The bottle label read, "For Single Use Only". RN #4 verified the finding.
On 05/19/10 at 0930, observations during a tour of the Medication Room in the Surgery Department with RN #5 revealed the following medications had been opened but had no label with a date or initials when opened:
AK Dilate 10%/5 ml (milliliters) bottle
Vigamox 0.5%, 5 ml bottle
Timolol GFS 0.5%, 5 ml bottle
Tetracaine Hydrochloride Ophthalmic Solution 0.5%, 15 ml
Lopidine 0.5% solution, 5 ml
Tobradex Ophthalmic Ointment 3.5 grams
The findings were confirmed with the Interim Operating Room Manager.
On 05/19/10 at 1000, observations during a tour of Operating Room #2 with the Interim Operating Room Manager revealed the following medications on the anesthesia cart had expired.
Promethazine 25 mg/ml, 1 ml - expired 02/10
Esmolol 10 mg/ml, 10 ml vial - expired 04/10
Albuterol Inhalation Aerosol - expired 09/09
The findings were confirmed with the Interim Operating Room Manager.
The facility's Policy #4050, Dating of open containers, stated, "..... Products not dated properly must be discarded....".

Based on observation, record review and interview, the staff failed to ensure that
equipment and supplies were properly maintained. The findings are:

During the initial tour of the facility on May 17, 2010 at 1230, there were
boxes of food stored directly on the floor of the cooler. The facility policy
currently in force allows such storage, per the Dietary Director in an interview
on May 17, 2010 at 1500. However, regulations require that all food stuffs
be stored off the floor on shelves. During the same tour of the Kitchen,
it was noted that the dishwasher temperatures were only being recorded
Monday through Friday, with no temperatures recorded on Saturday/Sunday.
The Staff was asked if the dishwasher was operated on the weekends and
the answer was in the affirmative. In an interview with the Director on May
17, 1020 at 1500, the Dietary Director was at a loss to explain why staff
had failed to record weekend dishwasher temperatures for at least the
past 3 weekends. There was no facility policy found that outlined the
procedure for recording dishwasher temperatures.
Also in the Kitchen, an unsecured Carbon Dioxide tank
was observed lying on the floor. There was no tank stand in the area, or straps for
holding the tank. The Dietary Director confirmed that the tank should be in a
holder, although no facility policy was found that described that all
pressured tanks should be secured in a holder.
During a tour of the Radiology Department, an unsecured Oxygen
tank was observed under a guerney in the main hallway. The Director of
Radiology confirmed it on the spot and had it removed. Again, no policy
could be found that required that a pressured tank be secured.




27544

On the days of the Recertification Survey based on observation and interview, the hospital failed to ensure that expired supplies were removed from crash carts. Furthermore, the hospital failed to provide for pediatric equipment on the crash carts in the Imaging Services and 2- East with the potential to affect all pediatric patients in an emergency.

The findings are:

On 05-18-10 at 1130, observation of the crash cart on the 2- East Nursing Unit revealed there were no defibrillator pads for pediatric use. The finding was confirmed with Registered Nurse #A on 05-18-10 at 1130. On 5-19-10 at 0820, observation of the adult airway box on top of the crash cart in the hallway of the Imaging Department revealed a #1- 8.5 millimeter (mm) endotracheal (ET) tube with an expiration date of 2003/06, #2- 6.5 mm ET tube with expiration dates of 2001-08 and 2005-2008, #1- 6.0 mm ET tube with an expiration date of 2002-07. There were no pediatric defibrillator pads for pediatric use. There was an infant Ambu bag, but not an Ambu bag for pediatric use. The findings were confirmed with the Director of Imaging Services and the Director of Respiratory Therapy Services on 05-19-10 at 1500.

Review of facility policy and procedure, titled, Emergency Crash Carts, reads, " ...2. Cardiopulmonary is responsible for restocking all respiratory equipment and supplies. Adult, pediatric and neonatal Ambu bags are kept on the cart...".

On the days of the hospital Recertification Survey based record review, review of hospital policies and procedures, and interviews, the hospital failed to provide the necessary follow up to implement discharge planning for patients seen in the hospital's emergency department for psychological issues that include but are not limited to suicide attempts for 1 of 3 patients in the hospital for psychological evaluation and involuntary commitment, and failed to have a plan in place to provide mental health back up when the area mental health personnel are not available for 1 of 3 patients reviewed for care and services. (Patient #18)

The findings are:

On 5/18/10 at 1100, a review of Patient #18's chart revealed that Patient #18 was admitted as an Emergency Room 1:1 Observation patient on 5/14/10 at 1354 for a suicidal attempt by drug overdose with a combination of drugs which include Motrin, Wellbutrin, and Darvocet.
The patient's chart had a hospital form, titled, Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/14/10 and was authenticated by the notary public or probate judge. Specific type of serious harm was recorded as 'Suicide". On Page 2 of the same form under "Note: To Police and Other Officers of the Peace" had this sentence underlined,"No person shall be taken into custody after the expiration date of three days from the date of the certification." The next section of the form, Part II, Page 1, titled, Certificate of Licensed Physician Examination for Emergency Admission, under 1. The UNDERSIGNED LICENSED PHYSICIAN, Have examined the above- named person and am of the opinion that the said individual:" (box) is checked that reads, "Is Mentally Ill AND because of this mental condition CURRENTLY POSES A SUBSTANTIAL RISK of physical harm to self and/or others to the extent that INVOLUNTARY EMERGENCY HOSPITALIZATION is recommended." The physician remarks included but were not limited to: "Took multiple types of medicines out of medicine cabinet. Some are Wellbutrin, Ibuprofen, Tylenol,Darvocet. PT (Patient) slightly lethargic. Pt took pills to end life due to .... taking children away. Medically cleared, Pt still unsure of another attempt." The Emergency Room Physician signed the form on 5/14/10 at 1340. Review of Part II, Page 2 of the form revealed that the sections that read, "I have consulted with the ________Community Mental health Center regarding Preadmission and Screening. If not, state clinical reason________" was blank. The section on the form for the name of the center, signature of face to face screener, and date, and printed name of screener, title and ID number were all blank.
Patient #18 had a 72 hour limited involuntary Application for Involuntary Emergency Hospitalization for Mental Illness, Part I / Page 1, dated 5/14/10 and was authenticated by the notary public or probate judge. The 72 hour period would have expired May 17, 2010. The patient's chart had no progress note by the Emergency physician dated 5/17/2010 that the Emergency room physician had seen the patient on 5/17/10. The chart had no evidence that any discharge planner or case management had seen the patient after admission or that any effort had been conducted to extend the involuntary emergency hospitalization for the patient. There was no documentation that the patient had received any mental health evaluation during the patient's stay. On 5/18/10 at 0935, the physician progress note reads, "S;...thinking straight, no longer suicidal, A: ...suicidal attempt - no longer suicidal, will D/C due to lack of bed & ...unable to assess. F/U at ... (clinic)". On 5/18/2010, the nurse recorded entries were at 0000, 0600, 0715 (having any thoughts of suicide, Regrets suicide attempt"), 0825 ("smoking in room, cigarettes and lighter confiscated"), 0905, 0930, 0945("pt to be discharged home"), 1000 ("denies suicidal ideation"), and 1005 ("Personal belongings returned") . On the Emergency Room form was a section labeled "Disposition:" which showed the following items were checked: discharged home, written instructions, prescription given to patient, and verbalized understanding'. The nurse authenticated the form and recorded the discharge time as 1012. Review of the hospital form, Emergency Department Discharge Instructions/ Drug Overdose Instructions, showed the form had no date, time, or was authenticated by staff. The instructions checked on the form with an x, read, "Rest today, increase activity tomorrow as tolerated; Resume normal diet; nothing was checked under the medication section; and Follow Up Appointment section had "Follow with mental health (call office for appointment) Phone #: ............ Appointment on 05/21/10 at 10 AM. On 05/18/10 at 1400, clinical record review did not show documentation of a consultation of Mental Health or placement attempts to a psychiatric facility. On 05/18/10 at 1500, Charge Nurse #7 revealed that he/she was unsure of what to do when the 72 hour time frame expired for involuntary emergency admission or the intended disposition of this patient. On 05/18/10 at 1500, the Discharge Planner reported that the patient was admitted on Friday (5/14/10) and he/she was not not notified of the patient's admission. The Discharge Planner reported that he/she was off on Monday (5/17/10) and assumed follow up when he/she returned to work on Tuesday, 05/18/10. The Discharge Planner verified that there had been no follow up for seeking a psychiatric placement for Patient #18 in his/her absence. The Discharge Planner reported that the Infection Control Nurse was supposed to be the back-up for discharge planning. The Discharge Planner reported that the hospital had an informal agreement with Mental Health in that the agency would come over to the hospital to assist with placement, and consultation for these patients, but Mental Health has informed the hospital that the agency can no longer assist the hospital with placement of these patient's due to their own increased case load. There was no evidence that the hospital had addressed the system issue of coverage for discharge planning for these patients on the weekends or in the absence of the discharge planner. On 05/19/10 at 0940, ER Physician #2 revealed that Mental Health was suppose to see the patients that are on ER Psychiatric Observation but the agency doesn't come on the weekends. ER Physician #2 reported that the patient on Involuntary Commitment after 72 hours had to have documented warranted behavior when the 72 hours expired, and/or depending on the patient's behavior of the last 24 hours of the commitment, the involuntary commitment could be extended or the patient could be released. Physician #2 reported that the patient was still an emergency department patient and the ER physician will see the patient every day while the patient is on the Medical Surgical floor. ER Physician #2 explained that the hospital was not accustomed to having 2-3 psychiatric patients at the same time on the Medical Surgical floor.

Hospital Policy, Seeking of Placement for Patient In Psychiatric Facility, dated October 2006 and revised July 2009, reads, "Mental Health shall be notified and see patient while they are initially in the ER. If patient presents during the hours of 9am to 5pm, the hospital social worker/discharge planner shall be notified and shall make efforts to expedite the placement of this patient. ....While on Observation status, mental health will be in charge of this patient until the time the patient is transferred or released due to contract for safety....". Based on interview with the Discharge Planner, ER Physician, and Director of Nursing, Mental Health was no longer seeing patients in the hospital for psychological issues due to their heavy case loads, and the hospital failed to institute a back up plan for monitoring these patients after the patient presented to the Emergency Department.

On the days of the Recertification Survey based on facility record review and interview, the hospital failed to have its agreement with the Organ Procurement Organization signed and dated.

The findings are:

On 05-18-10 at 0830, a review of the facility record LifePoint, Inc. Donor Hospital Memorandum of Agreement revealed that LifePoint did not sign and date the agreement and the hospital did not date the agreement. The finding was confirmed with the Director of Nursing on 05-18-10 at 0900.

On the days of the Recertification Survey based on observation, record review, review of hospital policies and procedures, and interview, the Operating Room staff failed to follow the hospital policy that the Warming Cabinet upper compartment temperature settings of 115 (F) Fahrenheit .

The findings are:

On 5/19/10, observations during a tour of the Operating Room revealed the Warming Cabinet's upper compartment temperature was set at 121 (F). Review of the hospital's operating room temperature logs showed the temperature in the warming cabinet had been maintained at 121 degrees (F) for several months. The finding was verified by the Interim Operating Room Manager who reported that he/she was not aware of the correct temperature for the warming cabinet which was stated in the facility policy.

On the days of the Recertification Survey based on interview and facility record review, the hospital failed to ensure that the preparation of radiopharmaceuticals were prepared under the direct supervision of a qualified physician or pharmacist. (Imaging Department-Nuclear Medicine)

The findings are:

On 05-19-10 at 0910, an interview with the Nuclear Medicine Technologist revealed that approximately once every 3 months the Technologist prepares Methylene Diphosphonate(MDP) with Technetium because of an add on test or an emergency and the radiopharmaceutical have to be mixed on site. The Nuclear Medicine Technologist prepares the radiopharmaceutical without direct supervision of a physician and/or pharmacist.
On 05-19-10, facility record review of radiopharmaceuticals revealed that on 03-11-10 at 1400, the Nuclear Medicine Technologist prepared Tc-99 NaTc04 with Medronate Kit Preparation without direct supervision of a pharmacist or physician. The finding was confirmed with the Director of Imaging Services on 05-20-10 at 0830.

On the days of the Recertification Survey based on observation, record review, review of hospital policies and procedures, and interview, the facility failed to ensure the hospital's Emergency Department (ED) policy 3.10 related to (Advanced Cardiac Life Support) ACLS Protocols were followed for 1 of 4 emergency department physicians and 3 of 7 Registered Nurses in the emergency department with a potential to affect all patients who presented to the Emergency Department.

The findings are:

On 05/19/10 at 1430, a review of licensed nursing personnel files and physician credentialing files revealed one (1) of four (4) ED physicians had expired ACLS certification and three of seven Registered Nurses had expired ACLS certification. The finding was verified by the Director of Nursing (DON) who stated that he/she was aware several staff members were not current in their ACLS certification. Emergency Department policy, 3.10 ACLS Protocols, reads, "All Emergency Department licensed nursing staff and ER physicians are required to take and stay up to date on their ACLS certification. .....".

On the days of the Recertification Survey based on record reviews and interview, the hospital failed to adhere to the hospital's policy and procedure for the respiratory therapy staff to obtain and maintain Advanced Cardiac Life Support (ACLS) certification with a potential to affect all patients receiving respiratory services in the hospital for 5 of 10 personnel reviewed with the potential to affect all patients receiving respiratory services at the hospital.

The findings are:

On 5/18/10 at 1300, a review of the hospital's employee files for the Respiratory Dept revealed that 5 of 10 employees were not currently ACLS certified. The personnel files showed that 3 of 10 Respiratory Therapists (RT) on staff had allowed their certification to expire, and 2 RT's had not acquired an initial certification. The findings were verified by the Director of Respiratory Services on 5/18/10 at 1530.
Facility Policy #2016, revised 5/08, titled, "BCLS (Basic Certified Life Support)/ACLS CERTIFICATION", states, "POLICY: All personnel, who have direct patient contact, will maintain CPR (Cardio Pulmonary Resuscitation) skills as evidenced by an annual or bi-annual update review or recertification class. All new healthcare personnel, who have direct patient care, are required to present verification of BCLS (Basic Cardiac Life Support) certification card upon hire. New Personnel:...It is the responsibility of the employee to maintain a current BCLS/ACLS certification and provide evidence of recertification according to policy and procedure. Existing Employees: It is the responsibility of the employee to maintain a current BCLS/ACLS certification and provide evidence of recertification according to policy and procedure...PROCEDURE:...ACLS Certification: All Respiratory Therapists will be ACLS certified within 90 days of employment. ACLS Recertification: All Respiratory Therapists re-certify their ACLS card every two (2) years, at least 30 days before expiration".

On the days of the Recertification Survey based on interview, employee record review, and hospital policy and procedure review, the facility failed to ensure that written policies and procedures for the Respiratory Department and Sleep/Wake Disorder Lab were reviewed and approved by the medical staff with a potential to affect all patients receiving respiratory services in the hospital.

The findings include:

On 5/18/10 at 0900, a review of the hospital's policy and procedure manual for the Respiratory Department revealed no documented review and approval of the manual since 2008. A review of the hospital policy and procedure manual for the Sleep/Wake Disorder Lab revealed that since opening the lab in July 2009, there had been no documented review and approval of the Sleep/Wake Disorder Lab policy and procedure manual. There was no documentation of a facility policy regulating the timeframe in which hospital policies are reviewed and/or revised.